Unintentional overdoses a growing risk

A Penn emergency-room doctor sees them all too often, due to increased reliance on opioid painkillers.

By David Sell, Inquirer Staff Writer

Posted: January 21, 2013

When the patients get to Jeanmarie Perrone in the emergency room at the Hospital of the University of Pennsylvania, they are sometimes already blue. Sometimes alive, but sometimes blue.

Lack of oxygen will do that to a body.

Overdoses of prescription opioid painkillers can cause depressed breathing, a lack of oxygen moving through the body, and then death.

America has a continuing epidemic of such overdoses, with more than 15,000 deaths per year, government agencies say, more than from cocaine and heroin combined.

Some of the dead fit the stereotype: young addicts pushing too far one night in search of a high, popping extra pills, or crushing and snorting them, or heating, liquefying and smoking or injecting them. But the highest rate of overdose deaths is among middle-aged people, according to the Centers for Disease Control and Prevention. America's concurrent obesity epidemic can add to the problem because extra weight can make breathing more difficult.

"I wish there weren't already so many people on pain medicine because it is very hard to stop opioid pain medicine that is already started," Perrone said last week after one of her shifts in the emergency room. "I would like a retro-wish and go back to the '90s, when we didn't prescribe as much."

The Drug Enforcement Administration is trying to reduce the public's reliance on pain pills. The U.S. Food and Drug Administration will hold hearings Thursday and Friday near Washington to discuss the DEA's request to make it harder to prescribe hydrocodone, the most commonly prescribed opioid painkiller.

IMS Health, a health-care technology and information company with an office in Plymouth Meeting, said that in 2011, more than 336 million prescriptions were written for painkillers of all types, not counting mail orders.

In the drug-classification system, smaller numbers mean more restrictions. Hydrocodone, a key ingredient in such brand-name drugs as Vicodin and generic versions, is a Class III drug. Oxycodone, a key ingredient in brand-name painkillers such as OxyContin and Percocet, and also generic versions, is a Class II drug. The DEA would like hydrocodone grouped with oxycodone, increasing the restrictions on its use.

Perrone, whose expertise is in emergency medicine and toxicology, is a member of the FDA advisory committee that will guide the hearings and eventually vote on a recommendation.

"Do you think that it is widely understood that of the deaths, a very, very large proportion are unintentional?" Perrone asked a reporter during an interview, meaning non-partying addicts.

No, she was told.

"These are not all people who are sitting in a room and injecting too much or smoking too much drug," she said. "Most of the overdoses are unintentional. They go to bed after a therapeutic dose and die in their sleep. I think most people think that it is the drug abusers using too many drugs, but it really is not."

Losing a loved one to an overdose is bad, no matter the intention, but Perrone's point underlies the problem of addiction to prescription pain medicine in America:

Unlike with illegal street drugs, doctors writing prescriptions give painkillers an acceptable route to family medicine cabinets, where the intended patient can become addicted and abuse the drug, or it can be taken by a family member of any age, abused, or resold.

Unlike illegal street drugs and the business around them, prescription pain medication is made by pharmaceutical companies, which might employ a neighbor or whose stock might be part of someone's 401(k) retirement plan.

Unlike with illegal street drugs, the federal government has urged the health-care community to study correct uses of pain medicine, and perhaps increase proper use.

Researchers at Dartmouth College have shown great variance in how often back surgery is performed, with some suggesting that it is performed only because patients complain and the surgeon gets paid extra. The surgery often fails to end or reduce pain, so medication is still required, and the surgery means higher costs to the health-care system. The alternative could be proper pain medication and physical therapy.

Endo Health Solutions in Chadds Ford is among the pharmaceutical companies that depend heavily on revenue from pain medication.

"Endo is committed to the responsible use of our products and takes steps to ensure that its products are prescribed and used appropriately through ongoing educational programming to physicians and other health professionals," Endo spokesman Kevin Wiggins said in a statement, noting that more than 114 million Americans suffer from acute and chronic pain.

"My whole campaign is to limit prescribing for minor pain - try to switch people to an alternative on the front end," Perrone said. "Don't give Percocet for a sprained ankle or dental pain. I wouldn't take it. I might be overinformed, but I wouldn't want my children to take it."

Perrone - who has children and said she takes no money from drug companies - said nonsteroidal painkillers like ibuprofen can work for bone and dental pain, menstrual cramps, and even kidney stones without the addiction risk of opioid painkillers. The addictive nature of opioids can require ever increasing doses for the same effect.

"We get pushed by the culture, that we are undertreating pain when we choose one of those vs. something stronger," Perrone said. "As a mom, would you rather have your child be in a little bit of pain or expose them to one of these meds?"

The doctor's prescription creates a gateway, for addictive medicine to get into homes, Perrone said.

"It used to be that you had to be in a whole different circle to go from being a good kid to trying heroin," Perrone said. "Now, we have some good kids who do some drinking and they have Vicodin in their family medicine cabinet and they wonder, 'Hey, what would this be like?' That's where we are."